Rhinoplasty: Open or Closed? What’s the Difference?

If you’ve ever considered plastic surgery of the nose, also known as rhinoplasty, then you’ve probably seen the terms closed rhinoplasty and open rhinoplasty. These two terms describe the surgical approach used by a plastic surgeon to perform cosmetic and functional rhinoplasty. Whenever I see a patient for rhinoplasty this is one of the first issues we discuss at the consultation. Patients often ask me which surgical approach is better, and which approach I use most often. The simple answer is that there is no right or wrong answer. The choice of open or closed rhinoplasty really depends upon the training and personal experience of the plastic surgeon.

I was fortunate to train in the era when both the closed and open rhinoplasty techniques were both commonly used. Therefore, I have performed hundreds of rhinoplasty operations with each approach. The only difference between the closed and open rhinoplasty technique is literally one measured in millimeters. Both approaches use incisions within the nose; the open approach simply adds an incision along the columella which is the skin between each nostril at the base of the nose. When closed in a careful and meticulous manner the resultant scar is virtually invisible within weeks of surgery.

At the initial consultation, I explain to my patients the difference between the two techniques and my personal preference based upon a comparison of the closed and open rhinoplasty approach. After 30 years performing rhinoplasty, I have found that the open or external rhinoplasty offers several advantages to the closed approach. First, the open approach allows the surgeon to see the underlying cartilage and bone directly, undisturbed, and interrelated. This is simply not possible in closed rhinoplasty as both the cartilage and bone are distorted and somewhat obscured by the overlying skin and soft tissue.

Secondly, the open approach allows more precise suturing especially when cartilage grafts are needed for support. The effects of suturing on the nasal cartilages are more clearly visualized in the open approach so that even subtle dynamic changes can be seen as the surgeon looks for symmetry and any distortion of the cartilaginous framework. Also, cartilage grafts can be secured more easily in the open approach with multiple sutures that may not be possible in a closed rhinoplasty.

Third, revision or redo rhinoplasty lends itself to the open rhinoplasty. In these challenging cases, scar tissue is commonplace. Asymmetric and uneven cartilages can clearly be seen as the result of prior rhinoplasty. It is much easier to both diagnose and treat the anatomic problems in revision rhinoplasty when the overlying skin and soft tissue are not in the operative field.

Critics of the open rhinoplasty often have little experience or training besides closed or endonasal rhinoplasty. Their criticisms include an obvious external scar; however, plastic surgeons are used to designing and closing facial scars as fine lines which are not seen, especially those along the base of the nose. Other criticisms of the open technique include prolonged nasal tip edema which has not been my personal experience. It is important to remember that the scar within the nasal columella is designed not as a straight line but as a geometric broken line which neither the eye or ambient light can easily detect. Furthermore, it lies within the “shadow” of the nose and can only be faintly seen when the head is tilted back and close inspection with a strong light is used.

In conclusion, rhinoplasty is one of the most interesting and challenging plastic surgery procedures we perform. It is more important for prospective patients to find a board-certified plastic surgeon who has experience with both initial and revision rhinoplasty, than to be overly concerned about the surgical technique which is used. Great surgeons will simply obtain consistently great results with either technique. If rhinoplasty is something you might be interested in, I encourage you to schedule a consultation at my San Deigo area practice. Together, we’ll address your goals and concerns in order to determine if the procedure makes sense for you.

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